Demeester Collaboration Transcript

Welcome to the Indiana University School of Nursing Interprofessional Collaborative Practice in Education Podcast Series. This podcast series was supported by grant funding from the Health Resources and Services Administration under the U.S. Department of Health and Human Services. The goal of this podcast series is to provide ideas and information to individuals interested in implementing interprofessional education or collaborative practice initiatives in their practice or educational setting.

In this episode, I'm talking with Dr. Debbie DeMeester, the assistant dean for pre-licensure programs at the Indiana University School of Nursing. Dr. DeMeester facilitated an interprofessional education experience on an acute care unit with undergraduate nursing students and 4th year medical students. We started out with a little bit of background about the types of interprofessional education experience that have been conducted prior to the grant project.

[DeMeester] So, with interprofessional education historically our experiences have been limited to nursing students and medical students with perhaps a third or fourth profession, professional student in our simulation labs, either here at the School of Nursing or over at Fairbanks. It has been difficult to find other professions to engage with us because of their busy schedules so it was often a volunteer situation —they might show up in jeans on their day off and there was a bit of a lack of realism. They are really very good. Um, many students are able to completely buy into simulation and learn just as though they were in the real clinical setting. Others, sometimes they have reported that 'oh, well, it's my medical faculty who's trying to act like a nurse' and they just say things that a nurse probably really wouldn't say and there's just kind of a lack of realism, so I think we don't always have that consistency of the fidelity in simulation, and of course we can start and stop when we want to. Um, if a simulation is not going the way we want it to go, we will often let it go for a while, but you know, we say, time. We call time and it ends. But, that's not the real world.

The other thing that we had been doing is having events where nursing students and medical students, and again, several other professional students would attend these large events at like, one of the event centers or large conference rooms here. And, they would work on a case study together.

[CPDLL] The team had planned another recent large event where older adults were going to come and provide health-related interviews with the students in order to practice history-taking and interviewing. Unfortunately the individuals could not attend at the last minute and a medical faculty member simulated the experience in a somewhat scripted way, which seems to be what often happens when trying to simulate these types of interactions.

Through the HRSA grant, the goal was to allow the students to learn together in a real-world acute care setting and be able to develop an actual care plan for a real patient as a team.

[DeMeester] The nursing student and medical student can see, um, how as a team they can really improve the outcomes of a real patient not the manikin.

[CPDLL] Now that we had some background on what had been happening in the past, Dr. DeMeester told us more about what the students did during the new interprofessional experience and how it was organized. One thing to note is that this experience occurred during a medical-surgical course not during an interprofessional course.

[DeMeester] This is a nursing student and they are junior-level nursing students because that is who we had on the HRSA grant units. Um, it's a great acute care, um, post-open heart unit with a lot going on. The biggest challenge in identifying who the appropriate level of medical student is who is available to come during, maybe, one of the busiest times when the nursing student is really engaged in what he or she does as a nurse. The medical faculty determined that the person who had the most flexibility was probably the sub-I —someone who is in their sub-internship so these are 4th year medical students.

[CPDLL] The first time this experience was implemented was at the very end of the sub-I's rotation, which may not have been the best timing. Initially, it was treated like a volunteer experience and the team realized that the medical students perhaps thought they were there in a teaching role and didn't really understand that there was a learning goal for them as well.

[DeMeester] An ah-ha moment for me was when one of them says, "oh! this is kind of like being an intern and you're on overnight call and you don't know anything about the patient." Because when they first came, they thought they were going to do like this whole work-up for an hour, and like no, this is just an hour-long experience.

[CPDLL] So this group is junior-level nursing students with medical students in their sub-internship. They start out with the nursing student giving report or handoff to the medical student.

[DeMeester] And what we learned the very first time was that the medical students really wanted a lot of additional information that the nursing student didn't even have available to them. So, the particular document that the physicians are most used to using we also need the nursing instructor who was overseeing the care of these patients with the students had that available as well.

We initially thought that they could probably do this handoff in about 5 or 10 minutes, and we noticed that it was really taking quite a long time. So, during the second year, we actually set aside at least 20 minutes to have this interaction because we found that there was a lot of learning that was going on both of their parts through this exchange of what about this, what about that, and they would look together for the information. So the first step is just getting a bit of a history and current status for, of the patient. You know, what are their labs and their vital signs, etc. etc. Then they decide together how they're going to approach the patient together. Who's going to ask what. What you think is important for us to include in this. We tell them to try to keep it to about 10 to 15 minutes, their time in the room. And, that's been quite interesting. These patients, they're the nursing students' patients, so they already know them. They have gotten the patients' verbal permission, you know, it's okay for one of the med students who's here assigned to this hospital as well to come in and do my next assessment with me. Sometimes they come back in about 10 to 15 minutes. The longest we've had is about 45 minutes where we've actually debriefed all the other students and had to do like a private debriefing with the team. It's really fascinating to see the wide variations in how much time they spend with the patient, but I would have anticipated this because this is the real world and you can't just walk in and cold cut and say, "OKAY!" This is  areal human being and we do tell them that, like, we recognize that this is a human being who has healthcare needs right now, so try to go in with your focus and do what you need to do, but if the patient needs something, obviously you're going to address that. And, so, we've had to be flexible and account for that as well.

So after they have done their assessment, they come back together and they compare what they're thinking is, and they have to come up with what does the team think the patient's number one problem that they could address. What's an outcome? What are three interventions? Could be something from the nursing realm, it could some type of medical intervention or some type of diagnostic test. But, these are essentially ideas of what could be included in the plan of care that could help the patient achieve that outcome. And, then they also think are all the other health professions involved in this patient's care, or have they not thought about getting OT or someone involved? So that's the final question that they address. And, so they sit down and they do that together.

[CPDLL] Initially they had the groups compare their information privately and then come together. But, due to time, they had to trim this to get the groups to focus on the problem, the goal, the suggested interventions, and what other professions they would suggest be involved.

[DeMeester] So, I'm kind of watching the clock, making sure that whoever the last group who's come in has had a little bit of time to sit down and work on that worksheet. So, they at least have a couple interventions—sometimes they really get hung up on that and they're thinking, and thinking, and thinking. And, at some point we do have to say, "ok, it's time to debrief."

[CPDLL] The team has done debriefing with two, three, or four teams of two, but they've found that the richest dialogue when there are four teams—four medical students paired with four nursing students as the students will jump in and start to converse more. One of the questions they posed is about the students' thoughts before they came and what they were expecting. The nursing students were surprised to hear that the medical students were also nervous or uncertain, specifically about whether or not they would know, well, everything they would need for the interaction and would feel confident.

[DeMeester] I think as we've gotten better at the organization of it and really knowing how to help them stay on track and preface it with the medical students, "this is kind of going to be like, this, imagine you're an overnight intern and you've called to see this." Um, okay, then they kind of get it, how it could benefit them as well. And, we get really, really positive feedback. We ask them to compare "what were the things you focused on," "what were the things that your partner focused on in the other discipline." And, they'll usually spend ten minutes or so talking about, "gosh, as a physician, I don't always necessarily always know what is the patient really eating, I forget about the weigh." And, the, what's been fascinating is the nursing students who have use of our clinical paperwork as busy-work— we'll have them, like write up the labs and diagnostic tests, and what meds they are on. And so they see these medical students—that's what they really want to know, and they'll talk about "oh! well, I want to know about their sodium or potassium, you know, because of this." And my sense is that it's helping the nursing students see "why is it important for me that I know that." And, I think it's add some value and realism into the clinical assignments we're having them do because it's not just because their instructor wants that but because other members of the healthcare team really care about the chest x-ray and the potassium level. It's not just because it's for your worksheet.

[CPDLL] Because some groups in year 1 were not coming back in a timely fashion to debrief, over the second year the team worked to make the instructions more explicit in terms of how many minutes to spend on each phase or on each activity on their list. Though patient interactions can't be as easily controlled as their needs are the priority, this strategy still helped groups stay on task and allowed time for debriefing, which could be considered to be the most valuable part of the experience.

[DeMeester] The most valuable for us in evaluating it, I think it is valuable for the students as well but that's that's the thing with patients is that you have to allow enough time. My suggestion was that it really takes about an hour and a half to do this from start to finish.

[CPDLL] But, what about pre-briefing or getting the students ready for the experience before it occurs?

[DeMeester] So, it is actually their, the nursing faculty, who is there on the unit who does the actual recruitment in terms of "are you willing to do this?" And, and I do spend about five minutes explaining why we're doing this and that's where I bring in that "imagine that you are an intern who's on overnight call. imagine that right now your patient is stable but imagine that you're concerned about something and you need to contact this physician. What are all these things you're going to want them to know."

[CPDLL] Individuals planning for this type of student experience need to look closely at the timing of medical and nursing student activities in that particular clinical setting as well as the level of the student involved.

[DeMeester] I think the timing, the figuring out when, where's the sweet spot in terms of where it's in everyone's—the patient and the two participants—to really get the most learning and the most benefit for the patient. One thing that has been fascinating for me is how important it is for the medical students to have those rounds, and they typically will gather at like 6:30 in the morning, and especially with a sub-intern, they are leading the rounds. And that's very important in how they are being evaluated as they are really getting ready to graduate from medical school, and that's a very, like sacred time and it's, it's very impactful and very positive for them to demonstrate for them that they can lead this team. And, this has to happen, so we initially thought why they don't just get together at 7, and that really wasn't in their best interest because that the time seeing that nursing handover and how a nurse organizes their day and and what he or she does and who they see first and, etc., versus, you know, going around, you know, the unit as the rooms come. And, so we identified that it really couldn't happen until 10:30, and it really needed to be done by about noon. So, we tried to do 10:30 to 11:30 and we felt very rushed in that we weren't really able to allow them express their truest feelings during debriefing because of feeling so rushed so, um ideally finding a 90-minute period of time that they could do this that they really want to have at least 20 minutes for debriefing.

The leveling of the student in the best situation, I think, a sub-I with, like, a senior nursing student would be ideal. I think that if a first-semester junior nursing student isn't really putting all of the pieces together, so, in terms of how they are feeling about it, they may not feel as confident. But, then I also have to think, you know, they're getting this very early, getting an understanding of that importance of why we have to look at all of these pieces of the puzzle. And, in retrospect, I think that that's okay.

[CPDLL] As the team as refined the process, the change in the experience for both students has been very obvious to them.

[DeMeester] It has been amazing this last year to see the collegiality, the give-and-take, even just how they sit together versus their, their body language. We do have RAs who are there taking notes of body language. I think that the body language has even become more positive because we've added this, this value statement of how it can benefit.

[CPDLL] I was really curious about Dr. DeMeester's observations regarding body language between the students, so I asked her if she would explain a little further what she'd observed.

[DeMeester] There were a couple of situations early on. So, the nurse gave report and a couple of the medical students took the chart document, the medical record document, looked at it and began to write their own notes and the nursing student was just sitting there. And, one of them even reported that a medical student reached over and took it from them. And, there wasn't quite a much interaction. For some teams it was very much like it is now for some, maybe, not leaning in as much, arms crossed listening to them giving their report or their handoff. Now, they were like, passing the document back and forth and talking about it and, like, pointing to it. And, as the medical students were writing things down, the, they were really doing it together. And, like, oh, they were sitting, like, next to each other. Cause we used to let them choose where they were going to sit, and we still do to some degree, but the nature of this room it just makes sense for them to be sitting next to each other. And, they're kind of in a corner of this very, very large table and they really are looking at what each other is writing together. And it's very calm; much less silence.

[CPDLL] The changes and interactions between the students were visible in other ways, too.

[DeMeester] There have been two times that I have had a really personal sense of fulfillment. One of those was the first time I saw the nursing student and the medical student leaving our little conference room and walking down that hall together toward the patient's room. I'm like, WOW!, how cool is that!

This past week was just as fulfilling. So, I stay back for about 10 minutes just straightening up and organizing. And, so I walked out and there were the eight of them in the hallway, like about halfway back to the unit. And I thought, hmm, I wonder what's going on. I didn't know whether, like, the other instructor was there like talking to them and as I got closer and closer, no! It was just the eight of them. And I passed them and kind of said to one of the nursing students, "is everything okay?" And, she said, we just can't stop talking about our experience.

[CPDLL] If you're looking to do a similar type of project with your students or in your setting, Dr. DeMeester has some recommendations for best practices and ways to help your program be successful.

[DeMeester] The right level of participants. As many professions as you possibly can gather; however, scheduling is a challenge, and while I would love to have maybe, a social worker or, with this unit being cardiovascular, a dietitian. You know, I'd love to have another profession involved in the clinical setting. That's a real challenge because of all the, you know, what's going on in the real world of health, health care. Having enough time. Letting them see what could be potential value for them. Getting their buy-in so they know they're not just doing this, um, as a favor to someone or for something fun to do.

[CPDLL] An additional support in place for this project was the presence of a champion from the medical field to  support the project with Dr. DeMeester.

[DeMeester] Early on I had someone who has a similar title as I do at the medical school. And, that person actually took a different position and I now have one of the hospitalists. She and I are together when the medical students come to the unit and I kind of go around and gather up the nursing students. We are like a united presence as well. We know what the debriefing questions are. We go back and forth between the two of us. She'll ask one. I'll ask a question. She'll ask the next one. I sit at one end; she sits at the other with the students, um, kind of between us so that we're together. We just thought it was important and maybe adding that value of why this is really valuable for both nursing and medicine that a nursing school faculty and a medical school—cause she has a faculty position as well.

[CPDLL] Of course this was a funded project with people and resources to support it, so in terms of sustainability of offering this type of experience moving forward, Dr. DeMeester told me that on another unit, the group is now trying out a different approach that they call a SWAP. The nursing student attends the sub-I's rounds in the morning, then later in the morning, when the sub-I has time he or she comes to the unit where the nursing student is that day. They spend about an hour together and the medical student can engage or assist in care with the nursing student. One challenge is that they do need to have a specific task or outcome that they need to accomplish as a result of the experience rather than just observing each other.

Another challenge is the debriefing period which is time-consuming and may not be realistic immediately following the experience. As clinical instructors have whole group on the unit doing a variety of tasks. In the project that Dr. DeMeester participated in, the grant and research team was able to provide the support to provide the debriefing, but obviously those resources are not always there.

This project and all the other projects conducted through this grant are moving us forward toward improvement of interprofessional collaborative practice one step at a time..

[DeMeester[ I think that fact that the eight students couldn't stop talking about it, um, says more than I could ever say.

[CPDLL] I want to thank Dr. Debbie DeMeester for taking the time to talk with me and to you for listening to this podcast. Make sure to check out the other recordings in the series as well as our continuing education activities at cenurse.iu.edu. Have a great day.